Catholic Health Initiatives National Leadership Conference

Saint Francis Medical Center is owned and operated by Catholic Health Initiatives. Several physician leaders from the community and myself are attending the national conference in San Antonio, Texas this week (October 26-27th, 2012).

In an attempt to continue building communication, especially with my colleagues in the community, I will be posting some thoughts and responses to the content of the conference on this blog during the conference.

I can also be followed on twitter: @heindoc

Stay tuned.

On Being a Physician

Much of my day to day routine is translating the mindset of the physician into the administrative side of medicine.

In that regard, some are surprised to hear my perspective on what physicians are feeling and experiencing. This article sums up the general perspective of physicians, even in Grand Island.

These are particularly challenging times in healthcare, and especially challenging for physicians. This breeds uncertainty.

Personally, I see opportunity and hope for physicians, especially as leaders. While I agree that medicine as we know it is coming to the end of an era, the future for physicians who are both system-minded and clinically astute is bright.

The Future of US Healthcare

No one can predict the future, but the future is not unknowable. While no one may be able to accurately predict the future of US healthcare, we do know something about what it will look like.

Some will want to understand why we need to change the way we deliver care. This YouTube video by Dr. Barry Bittman is a helpful introduction to the challenges we face. Simply put, we cannot continue to deliver care in the same way we have for the past 60 years.

The stakes are very high. We must find a way to improve the overall health of a given population, accomplish that at the lowest possible per person cost, and in a manner that engages and satisfies the patient’s right to a positive experience. The risk of failure or inaction far exceeds the risk of change. To do nothing is paramount to accepting the economic demise of the United States.

The future of US healthcare requires redefining what healthcare means: moving away from episodic sick-care to sustained preventive care, from provider-centric care to patient-centric care, from hospital-centric care to point-of-resident care, from professional-based knowledge to consumer-based knowledge and decision making.

The path forward will include some combination of the following realities: team-based care, technology and non-physician supported chronic disease management, integrated health delivery systems, data and results-driven population management, as well as a strong patient-centric focus.

The transformation will be highly disruptive. It will result in a redefinition of the roles and responsibilities for health care providers, a deconstruction of the medicalization of US society, and a higher degree of personal responsibility.

We are moving into very interesting times, both challenging and exciting. Change is never easy, but change we must.

“There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries … and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it.”

Niccolo Machiavelli, The Prince, Chapter VI, 1532


At the most recent quarterly medical staff meeting I presented the results of the physician’s satisfaction survey, the focus group, and my responses to the information provided.  Part of my response was directed at SFMC’s past effectiveness at implementing change efforts. Most often, both in the focus group and from direct communication with physicians, this has been relayed to me in a simple statement: “Nothing ever changes.” Usually that comment comes with frustration, because the physicians want things to improve. That’s a good thing. It means physicians care.

My observation is that SFMC is eager to improve anything for the patient. Likewise, the organization, meaning staff and management, want to please the physicians. They care deeply about what they think and want to be responsive and helpful.  This is a good thing. It means the organization cares.

It’s a puzzling paradox. Physicians and the organization want things to improve for the patient.  Clearly, things stay the same (if they do stay the same) not for want of desire for change.

Another premise offered by some physicians is that there is an ability deficit. It’s not that there is a lack of desire by SFMC but a lack of management skill in pulling off change. I disagreed. If that were the case, then we wouldn’t see improved patient satisfaction scores (now exceeding the 94th percentile in the HealthStreams national database), or core measures (a 6% increase improvement in 12 months), or new technology, physician services, and any number of adaptations to the ever changing healthcare environment. These things did not occur by happenstance. It took leadership to pull it off.

I don’t think it’s about ability or willingness. Simply put, most change efforts fail. They fail for everyone, in every business, including healthcare and Saint Francis. Change management and leading change are topics of textbooks. But there are key sequential steps which must be achieved in order for change to be successful and be sustained. [1] The textbox shows eight steps which must be followed sequentially in order for change efforts to be successful and to stick.

Kotter’s 8 Steps of Change

1) Create urgency
2) Form a powerful coalition
3) Create a vision for change
4) Communicate the vision
5) Remove obstacles
6) Create short-term wins
7) Build on the change
8) Anchor the changes in Corporate Culture

Think about your past experiences with major change efforts in your clinic or at SFMC. If you think of a success story, you’ll see how these steps were applied. If you think about change efforts that didn’t stick, you’ll where steps were missed.

When I hear about problems that “never change” at SFMC, it tells me that what needs to be changed is difficult and complex. These are issues that will require substantial contribution from all involved, persistence, and attention to the realities of change. Most often, as clinicians, we are tempted to shoot from the hip, give an order, or tell someone to fix something, and move on. We are trained to think this way and act this way. But that doesn’t serve us well when we are attempting to deal with complex, large problems. Then it becomes more like internal medicine than surgery; requires a rigorous scientific method-based methodology, involving teams made up of multiple disciplines, and leadership attentive to the realities of the 8 steps of change.

This reality is part of the reason why I continue to appeal to physicians to roll up their sleeves and participate in major change efforts. Without exception, physicians are part of the “powerful guiding coalition” step. Without you, change efforts will fail. With you, we have hope and opportunity for moving forward and addressing those things that have ‘never changed’ before. Join us in the journey to exceptional patient care.

[1] Kotter, JP Leading Change: Why Transformation Efforts Fail, Harvard Business Review, Jan, 2007 #R0701J-PDF-ENG

Superbugs and Threats to our Community

Recently I read a USA Today article on Clostridium Difficile (C.Diff) infections that I’d like to share. Sometimes when we read about issues in a national publication we can be lulled into a sense of security because the people affected are far from us. We don’t know them.

C. Diff. is a real threat to us in Grand Island. At Saint Francis Medical Center (SFMC) medical center we track these infections monthly. Historically this infection was caused by use of antibiotics in the hospital. Hence it was labeled as a “Hospital Acquired Condition,” is reported to regulatory agencies monthly, and we have responded by vigorous antibiotic stewardship in the hospital.

For some years our rate of C. Diff. infections at SFMC was quite low. Like most places in the United States, In the past 12 months we have seen a steady increase in the number of C. Diff. infections at SFMC. The difference from past infections is that these C. Diff. cases are coming from the community, not from within the hospital. This is concerning.

Our response needs to be a more thoughtful use of antibiotics in the community, reserved for true bacterial infections, using the right antibiotic for the right condition, and avoiding broad-spectrum antibiotics when unnecessary. Everyone has a part to play in antibiotic stewardship, including patients, families, and providers.

For the sake of us all, let’s work together to learn about antibiotic stewardship.

Bundled Payments: More than Theory

“Every system is perfectly designed to get the results it gets.” ~ Paul Batalden, M.D

In the United States, we are paid for doing stuff. This is fee for service. And we do stuff better than anyone else in the world. This has created a health system that is potentially accessible, exceptionally sophisticated, and expensive. So expensive that many can no longer afford it and have no access.

In our society, if you don’t get paid for something, you’re less likely to do it – unless it somehow makes it more likely you’ll increase what you do get paid for. After all, healthcare is a business. You do have to pay the employees and the bills.

We generally aren’t paid for prevention or coordination. In fact, under fee-for-service, we are rewarded for the consequences of doing those things poorly or not at all. While definitely our mission, and clearly important, on a pure fiscal basis, it’s hard to be excited about preventing ED visits, reducing readmissions, and decreasing utilization. Those very things keep nurses employed, floors full, and the lights on. For most non-profit hospitals in the US, the operating margins are around 2 to 3%. Doing what we do as opposed to not doing what we should do better, for many, is an issue of survival.

Imagine with me what would happen if we were paid for quality, exceptional patient experience, penalized for excessive volume, and rewarded for efficiency. I can imagine that there would be far better interdependent coordination and management of care between primary care and specialists. I can imagine a substantial decrease in unproven procedures, medications, and unnecessary tests. I can imagine a system bending itself to align with the needs and preferences of patients, rather designing things that are most convenient for us. I can envision a system that vigorously supports transitions of care, or eliminates them. I can predict a dramatically improved cost accounting system that allows management to fully understand and predict the explicit costs associated with an episode of care, so that they can maximize efficiency and thereby be fiscally rewarded. I imagine that his type of payment reform could change everything.

This is what policy makers are striving for with healthcare reform.

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How the Accountable Care Act Changes Everything

 The idea of bundled payments – paying a set dollar amount for an episode of care – is not new. In the early 1990′s, CMS sponsored a demonstration project. It was successful at reducing costs. Since then several other projects have demonstrated the same results.

The accounting is pretty straight-forward. CMS calculates an expected cost for an episode of care, around a specific condition or surgery. They negotiate a specified time period that defines the episode, and then agree to a payment amount that is a few percentage points below the expected cost for that episode. If the actual cost for an episode is less than the negotiated price, the provider pockets the difference; if the cost exceeds the negotiated price, the provider eats the loss. Providers assume the risk, not CMS. In this scenario, CMS wins because they realize a cost savings, and, if the provider is sophisticated, understands the drivers of cost, and works to reduce them, they can do well. Patient’s win because costs are reduced, quality is maintained, and providers stay in business. 

While these demonstration projects have been win-wins, before they could be spread nation-wide, CMS had to seek congressional approval. This is where things became difficult and lobbyists realized their opportunities.

In healthcare, every dollar of cost reduction is someone’s paycheck. I don’t think that’s absolutely true, but the beneficiaries of an inefficient, high cost system definitely know a threat when they see one. They made certain that these demonstration projects never received congressional approval. For the most part these projects have sat gathering dust on a shelf for the past twenty years.

The Patient Portability and Accountable Care Act changed this situation. CMS was granted permission to establish an innovation center and to spread changes from pilot programs to a national level without congressional approval. Therefore, when projects show success, we can expect rapid and nationwide implementation.

 Many experts believe that bundled payments, now in the early stages of piloting, will be successful. Some expect rapid, nationwide implementation of this payment model as early as 2015.

 If that happens, everything changes.

Related Reading:  The founder of LeapFrog’s perspective on payment reform.  


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When leaders listen, they learn.

I want to thank John Wagoner. He spoke. I listened. And I learned something important about organizational communication.

Soon after my arrival at SFMC I observed an opportunity for improved communication to physicians. Information is the lifeblood of effectiveness. We are relying on mailboxes and quarterly staff meetings to share our most vital information. Like coarctation, relying on these two channels alone severely restricts the free flow of information and subsequently hampers our ability to adroitly adapt to our changing environment. This concerned me, but John expanded my understanding of why we should be concerned.

 He shared that one consequence may be the unintentional creation of an ‘in the know’ group and a ‘not in the know’ group. One group more involved and the other less so. One group is more aware, the other unaware. Therefore, one more amenable and adaptable to, and the other surprised by, change.

Because some see surprise as equivalent to resistance, over time, some individual physicians or physician groups are labeled as “trouble-makers” or “resistant.” Preconceived perceptions of participatory unwillingness hamper communication – people are more reluctant to interact with them – creating the proverbial negative feedback loop.

We need to be careful. Incredulity is not equivalent to resistance, especially if the response is due to a lack of information. And if the lack of information is because there are structural deficiencies, such as a department that no longer meets, then we need to take ownership of those deficiencies and correct them.

Divisions are critical communication distribution channels, and provide fertile ground for peer-to-peer education, accountability, communication, and leadership development. Without them, we create an organization that favors false labels and significantly hampered adaptability.

We continue to expand communication channels to physicians. This blog is one example. But we also need to make certain that the formal organizational structures support the adequate exchange of information.

Thank you to John Wagoner for the illumination.


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Sideways Corduroys and Disruptive Innovation

 I read those back-of-the-airplane-seat magazines. I never used to, but then the Kindle happened, followed by the IPad. You can’t use electronics during takeoff, so I pull the magazines out. I’m now a back-seat magazine connoisseur. If the Kindle and IPad hadn’t happened, I would be less educated. Trust me, you can learn some stuff. Like, who’s the world’s best Sushi chef .

Another example. What do you know about sideways corduroys? They reportedly reduce drag by an amazing 16.24%. And the company, Betabrand, created a market out of people who were never interested in shopping for clothes. Like many other disruptors, it started in a basement, on a laptop, by someone who had no experience in and knew nothing about the clothing industry. He had no idea that you were supposed to create clothes seasonally, to own warehouses stocked with inventory, to replicate fashion designers.

The company doesn’t use models to show their clothes, they use real customers. They communicate via FaceBook, Twitter and other internet-based solutions, and not mass media. They rapidly respond to ideas their customers offer. They individualize. They are decoupled from the established industry.

They don’t think outside of the box, they are outside of the box. So far out that they seem careless about what was supposed to be. The established industry is irrelevant. They saw a need and met it.

There’s a lesson for us in healthcare. It’s not a matter of if, but when. Because we are expensive, are frequently inaccessible to patients when they want and need us (Report Card), aren’t really patient-centered, have not moved into the 21st century, someone will begin building a new way of doing healthcare. It will be cheaper, more accessible, and will support and improve health. Patients will prefer it.

When this happens, it will not look like anything we’ve known for 100 years. It will be consumer-driven and not provider-centric, far less institutional and more home-based. There will be substantial non-professional self-care (read: less professionals), digital, mobile and increasingly virtual.

General Eric Shinzeki is reported to have once said, “If you don’t like change, you will like irrelevance even less.”

I can see some of the smirks and hear the guffaws. Like us, that’s just what the aristocracy was doing at a dinner party the night before July 14, 1789.  It’s just about as funny as sideways corduroys.

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Serendipity, Sushi, and Sitki

I happened to bump into Sitki Copur in the Grand Island airport. He was flying to Dallas, I was on my way to Boston. The meeting was pleasurable serendipity. Sitki is the consummate physician-scholar. We shake hands, he flashes his distinctive unassuming smile, and I feel welcome and appreciated. If it hadn’t been for an article about Sushi the greeting would have remained nothing more than notably nice. Sitki and the story highlighted for me a critical element of effective physician leadership

Jiro Ono owns and serves Sushi at Sukiyabashi Jiro in Tokyo. He is world renown. His ‘restaurant’ seats 10. To get a seat you have to make reservations more than a month in advance. You pay a minimum $390 for 20 pieces of sushi. That’s at least $19.50 per small piece of cold fish. This begs the obvious question: Why? The answer: Perseverant Passion.

Jiro Ono is 85 and he dreams about how to make sushi better. He’s done that for 60 years. He says, “While I’m making sushi, I feel victorious.” He has found his True North.   Hopefully the Saint Francis Cancer Treatment Center team, like Jiro Ono, feels victorious. They have a perseverant passion, Sitki has found hisTrue North, and our patients have reaped the reward.

Passion makes all the difference. The oncology team received yet another highly prestigious recognition: certification by the Quality Oncology Practice Initiative (QOPI®), an affiliate of the American Society of Clinical Oncology (ASCO). Cooperative, effective, team-based leadership and a relentless focus on continuously improving patient and family-centered care is what led to this accolade. A physician leader in partnership with other healthcare leaders is a powerful amalgam. It almost always results in just the sort of high quality healthcare patients deserve. And this, in of all places, happened in Grand Island, Nebraska, where sushi is rare, less expensive than Sukiyabashi Jiro, and really good at Wasabi.

There are many days I wonder, “What kind of care would patients receive from us if we all embraced our True North our own perseverant passion?”

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